Final Long

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A 60 year old male patient driver by occupation came to  causality with the chief complaints of

 - Pedal oedema since 15 days.  

- Shortness of breath since 5 days.   

- Fever since 5 days. 

- Decreased urine output since 3 days .                                                                                                       

HISTORY OF PRESENT ILLNESS;

He was asymptomatic 15 days back after which developed oedema in his lower limb which is extended up to ankle which is pitting type

- Fever which is continuous associated with cough and vomiting  since 5days.

- Vomiting of one episode which is non projectile. 

- Cough with sputum which  is red in colour and reduced after medication.

- SOB of grade 4 since 5 days

PAST HISTORY;

-He had a H/o giddiness 15 years back for which he went to hospital and diagnosed with diabetes and he discontinued medication since 6 years.

-He had H/o TB 15 years back which is treated with HRZE regime.

- Diagnosed wit hypertension since 2 years.

- He is a known case of chronic renal failure and he is on hemodialysis and he underwent 4 sessions of hemodialysis.

PERSONAL HISTORY;

Diet -mixed

Sleep - adequate

Appetite- Normal

Alcoholic since 30 years.

FAMILY HISTORY;

No relavent family history.

GENERAL EXAMINATION;

- Patient was conscious, coherent, not well cooperative

- Pallor present

-No cyanosis, clubbing, lymphadenopathy.

-pedal oedema which is pitting type.

VITALS

Temperature -99.6 F

-B.P-140/80mm Hg

PR-85bpm

RR-26cpm

GRBS -237mg

Systemic examination

CVS : S1 & S2 Heard

Respiratory System : Bilateral Airway Entry present

Per abdomen - soft, nontender, No abnormal Mass 

CNS -NAD

INVESTIGATIONS

ECG

Haemogram :

Hb- 7.1 gm/dl

TLC- 12,500

Lymphocytes -13

PCV -21.6

MCH- 22.7

RBC count- 3.13 million /cumm

Renal Function test:

Urea-132 mg /dl

Creatinine -10.1 mg/dl

Phosphorus -6.6 mg /dl

Liver Function Test: 

Total bilirubin -0.76

ALP - 141

 Total protein -5.8 gm/dl

Albumin -2.7 gm/dl

Complete urine culture

PROVISIONAL DIAGNOSIS;

CKD on MHD

FINAL DIAGNOSIS;

Diabetic NEPHROPATHY.

Treatment;

Salt restriction-<2.4 gm/day

Fluid restriction <1 lit/day

Tab lasix 40 mg

Tab SHELCAL 500 mg.

INJ.PAN 40MG 

INJ.ZOFER 4mg

Tab NICARDIA 5mg

Tab Nodosis 500mg 

Tab orofer .